Arun B. Jesudian, MD: So, Steve, I’ll give you this question then. If we’re not checking ammonia levels, how are you going to classify the severity of someone’s hepatic encephalopathy? And specifically, if you wouldn’t mind talking about the West Haven criteria, which are perhaps the most widely utilized.
Steven L. Flamm, MD: When you’re talking about overt encephalopathy, which is encephalopathy that’s clinically diagnosed, it’s what health-care providers, and patients, and their families care the most about. This is diagnosed clinically. You know a patient has cirrhosis and portal hypertension, and they have the signs and symptoms compatible with HE and you treat it, not with ammonia levels. It’s a clinical diagnosis.
Now, within the context of overt encephalopathy, when you make that diagnosis on a patient, as I mentioned earlier, there is a very wide spectrum of presentation. And there are 4 stages, not counting stage 0, which means you don’t have encephalopathy. There are stages I through IV of encephalopathy. Stage I is under the rubric of minimal, or I should say it’s under the rubric of covert encephalopathy. This group of patients have very subtle symptoms, symptoms that are so nonspecific that it’s hard to even necessarily attribute them to encephalopathy, like fatigue, like changes maybe in work performance, sleep/wake reversal, very early changes that aren’t really definitive mentation changes.
Once you start to get to II, III, and IV, this is where we call it overt encephalopathy rather than covert encephalopathy. Stage II is probably the most common. That’s where patients start to have personality changes, inappropriate behavior, maybe slurred speech. This is where patients first start to develop asterixis, the flapping of the hands, stage II. Frequently, but not always, these patients are hospitalized. Stage III, which is less common, is much more serious even. And this is where patients have overtly bizarre behavior. They may be stuporous. They’re not in a coma, but they’re really not responding to questions at all appropriately. Stage III, these people are all admitted often to the ICU [intensive care unit]. And then stage IV is coma, and the coma may be responsive to noxious stimuli or unresponsive to noxious stimuli. Either way, these patients are almost always hospitalized in an intensive care unit.
So the actual grade or the class from these criteria is not critical in private practice, I would say. We use it in research. It’s important, but for the practitioner to grade it, it’s not critical. Certainly, when you have a patient with HE you should document in the chart a little bit what their signs and symptoms are, so that when you see the patient and when others see the patient in following days, they can get an idea of how the patient is doing. Are they doing worse or are they doing better? Not just [that] they have HE. What are the issues, because I think it helps you know if the patient is responding to therapy.